A nurse is providing teaching to the parents of a newborn who has a prescription for a home phototherapy biliblanket.
Which of the following statements should the nurse include in the teaching?
You will check your baby's bilirubin level every 6 hours.
You should offer your baby glucose water 1 hour after each feeding.
Your baby's eyes should be covered while on the biliblanket.
You can remove your baby from the biliblanket for feedings.
The Correct Answer is D
Choice A rationale
Bilirubin levels are typically monitored by a healthcare professional and not by parents at home every 6 hours. The frequency of bilirubin checks for a newborn receiving home phototherapy is usually determined by the healthcare provider based on the infant's bilirubin trajectory and clinical status, often daily or as prescribed.
Choice B rationale
Offering glucose water to newborns is not recommended. Glucose water does not provide adequate nutrition and can interfere with successful breastfeeding or formula feeding by reducing the infant's appetite for nutrient-rich milk. Adequate hydration and nutrition are crucial for bilirubin excretion in jaundiced infants.
Choice C rationale
For biliblanket phototherapy, eye coverings are generally not necessary. The biliblanket emits light from a fiber optic pad that is wrapped around the infant's body, and the light does not directly shine into the baby's eyes, unlike traditional overhead phototherapy lights that require eye protection.
Choice D rationale
Removing the baby from the biliblanket for feedings is appropriate and encouraged. Intermittent breaks for feeding and bonding are permissible as long as the total duration of phototherapy prescribed by the healthcare provider is met. Frequent feedings promote bilirubin excretion through stools.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering oxygen via nasal cannula at 2 L/min might marginally increase fetal oxygenation, but it does not address the primary issue of hypotension causing decreased placental perfusion. The fundamental problem is reduced blood flow to the placenta, necessitating interventions that increase maternal circulating volume and blood pressure to improve perfusion.
Choice B rationale
Administering a lactated Ringer's 500 mL bolus directly addresses hypotension by expanding the maternal intravascular volume. This increased circulating volume raises blood pressure, thereby improving placental perfusion and oxygen delivery to the fetus. Lactated Ringer's is an isotonic solution, effective for rapid volume expansion.
Choice C rationale
Placing the client in a knee-chest position is typically used to alleviate cord compression or prolapse by shifting the fetus, not for treating hypotension. This position can actually worsen hypotension by trapping blood in the lower extremities and reducing venous return to the heart, further compromising placental blood flow.
Choice D rationale
Monitoring the client's blood pressure every 30 minutes is a crucial assessment but is not an immediate intervention for acute hypotension with decreased placental perfusion. While ongoing monitoring is essential, immediate actions are required to correct the underlying cause of hypotension and restore adequate blood flow to the placenta.
Correct Answer is D
Explanation
Choice A rationale
Urinary output of 20 mL/hr is indicative of oliguria, which is a significant adverse effect of magnesium sulfate therapy. Magnesium is renally excreted, and decreased urinary output can lead to magnesium toxicity. The desired urinary output for a client receiving magnesium sulfate should be at least 25 to 30 mL/hr to ensure adequate drug excretion.
Choice B rationale
Fetal heart rate pattern with minimal variability is a concerning finding and can indicate central nervous system depression in the fetus, potentially due to excessive magnesium levels. Normal fetal heart rate variability reflects a healthy autonomic nervous system. Magnesium sulfate's therapeutic effect is on the mother, not directly on fetal heart rate variability.
Choice C rationale
A change in fetal heart rate from 150/min to 166/min, while still within the normal range (110-160 bpm), does not directly indicate the desired therapeutic effect of magnesium sulfate for preeclampsia. This fluctuation could be due to various factors and is not a primary indicator of successful seizure prophylaxis or blood pressure control.
Choice D rationale
Magnesium sulfate is a central nervous system depressant that works by blocking neuromuscular transmission, thereby reducing hyperreflexia associated with preeclampsia. A decrease in deep tendon reflexes from 4+ (hyperactive) to 2+ (normal) indicates that the medication is achieving its desired therapeutic effect of central nervous system depression and reducing seizure risk.
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